ABSTRACT This study assessed whether states that lowered legal blood alcohol limits from 0.10% to 0.08% in 1993 and 1994 experienced post-law reductions in alcohol related fatal crashes.
Six states that adopted 0.08% as the legal blood alcohol limit in 1993 and 1994 were paired with six nearby states that retained a 0.10% legal standard. Within each pair, comparisons were made for the maximum equal available number of pre-law and post-law years.
States adopting 0.08% laws experienced a 6% greater post-law decline in the proportion of drivers in fatal crashes with blood alcohol levels at 0.10% or higher and a 5% greater decline in the proportion of fatal crashes that were alcohol related at 0.10% or higher.
If all states adopted the 0.08% legal blood alcohol level, 400-500 fewer traffic fatalities would occur annually.

[Show abstract][Hide abstract]ABSTRACT: The USA leads the developed world in motor vehicle fatalities, presenting a critical public health threat. We examined whether an increasing share of mass transit use, relative to vehicle miles traveled on public roads, was associated with reduced motor vehicle fatalities. We used annual city-level data for the USA from 1982-2010 provided by the Fatality Accident Reporting System, the Texas A&M Transportation Institute, the Census Bureau, and the National Oceanic and Atmospheric Administration to estimate a structural equation model of the factors associated with mass transit miles and motor vehicle fatalities. The final analytic data included 2,900 observations from 100 cities over 29 years. After accounting for climate, year, and the economic costs of driving, an increasing share of mass transit miles traveled per capita was associated with reduced motor vehicle fatalities. The costs of congestion to the average commuter and gas prices were positively associated with increasing the share of mass transit miles traveled. The economic costs of driving increased over time, while both the fatality rate and the share of mass transit miles traveled decreased over time. Increasing the share of mass transit miles traveled may be associated with fewer motor vehicle miles traveled. Increasing mass transit uptake may be an effective public health intervention to reduce motor vehicle fatalities in cities.

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ORIGINAL ARTICLESEVects of recent 0.08% legal blood alcohol limitson fatal crash involvementRalph Hingson, Timothy Heeren, Michael WinterAbstractObjectives—This study assessed whetherstates that lowered legal blood alcohollimits from 0.10% to 0.08% in 1993 and1994 experienced post-law reductions inalcohol related fatal crashes.Methods—Six states that adopted 0.08% asthe legal blood alcohol limit in 1993 and1994 were paired with six nearby statesthat retained a 0.10% legal standard.Within each pair, comparisons were madefor the maximum equal available numberof pre-law and post-law years.Results—States adopting 0.08% laws expe-rienced a 6% greater post-law decline inthe proportion of drivers in fatal crasheswith blood alcohol levels at 0.10% orhigher and a 5% greater decline in theproportion of fatal crashes that were alco-hol related at 0.10% or higher.Conclusions—If all states adopted the0.08% legal blood alcohol level, 400–500fewer traYc fatalities would occur annu-ally.(Injury Prevention 2000;6:109–114)Keywords: fatal crash; legal blood alcohol limit; drunkdrivingTraYc crashes are the leading cause of deathfor persons between the ages of 1 and 24 in theUnited States1and alcohol is involved in nearly40% of fatal traYc crashes.2In 1998, 15 935persons died in alcohol related traYc crashes2and approximately one million are injured eachyear.3Those deaths and injuries cost the nationover $45 billion in lost economic productivity,hospital and rehabilitation costs.3To reduce alcohol related traYc deaths, 17states have lowered their criminal per se legalblood alcohol limit from 0.10% to 0.08%. Toreach 0.08% blood alcohol content (BAC), a170 pound (77.1 kg) male would have to con-sume four drinks in one hour on an emptystomach, and a 135 pound (61.2 kg) femalewould need to consume three drinks in onehour.3Experimental laboratory studies have shownthat at 0.08% BAC, driving performance isimpaired. At 0.08%, there is reduced periph-eral vision, poor recovery from glare, poorerperformance on complex visual tracking, andreduced divided attentionDriver simulation and road course studies haveperformance.4revealed poor parking performance, impaireddriving performance at slow speed, and steer-ing inaccuracies.5Roadside observational stud-ies have identified speeding and breakingperformance deterioration.6A national com-parison of drivers in single vehicle fatal crasheswith drivers not involved in crashes stopped atroadside indicated that each 0.02% increase inBAC nearly doubles the risk of fatal crashinvolvement.7In all age and sex groupings at aBAC of 0.05%–0.09%, the fatal crash risk wasat least nine times greater than at zero BAC.Many countries have established blood alco-hol limits at 0.08% or lower.3Austria, Canada,the United Kingdom, and Switzerland have0.08% blood alcohol limits. Legal limits rangefrom 0.05%–0.8% in Australia, and are at0.05% in Finland, France, Germany, theNetherlands,Norway,and Japan.Sweden has alegal blood alcohol limit of 0.02%, a level simi-lar to the zero tolerance laws for drivers underage 21 now found in all states in the UnitedStates.In California, the largest state to adopt a0.08% law, researchers found a 12% decline inalcohol related fatal crashes after the law wasadopted (National Highway TraYc SafetyAdministration,1991).Because California alsoadopted an administrative license revocation(ALR) law six months after the 0.08% per selaw, the separate eVects of each law were diY-cult to determine. According to one study,most of the eVects occurred after the ALR pro-visions were added (Rogers, 19958).Johnson and Fell monitored six measures ofdriver alcohol involvement in the first five statesto adopt 0.08% laws (Utah, Oregon, Maine,California,and Vermont) and identified severalstatistically significant pre-law to post-lawdecreases.9Because the study did not comparestates with the 0.08% law to states that did nothave the law, researchers could not determinewhether the changes were independent of gen-eral regional trends. The researchers didconclude the eVects of the law were independ-ent of national trends.Another study, conducted by the authors ofthis report, examined the first five states tolower legal blood alcohol limits to 0.08% rela-tive to nearby states which retained 0.10% asthe legal limit. These 0.08% law states experi-enced a 16% greater post-law decline in theproportion of fatal crashes that involved afatally injured driver with a BAC of 0.08% orThis article is dedicated toRoss H and Geri JGoughler who in 1992,while traveling to aThanksgiving visit withtheir daughter,were struckand fatally injured by adriver in New Mexico.Police reports indicated thedriver had been drinkingbut his blood alcohol levelwas below 0.10%,the legallimit at the time.He wasnot charged with a drunkdriving violation.Injury Prevention 2000;6:109–114 109Boston UniversitySchool of PublicHealth: Social andBehavioral SciencesDepartmentR HingsonEpidemiology andBiostatisticsDepartmentT HeerenData CoordinatingCenterM WinterCorrespondence to:Dr Ralph W Hingson, Socialand Behavioral SciencesDepartment, BostonUniversity School of PublicHealth, 715 Albany Street,T 2W, Boston, MA 02118(e-mail: rhingson@bu.edu)

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higher.10which had parallel pre-law trends in theproportion of fatally injured drivers with BACsof 0.08% or higher, similar population sizesand geographic proximity. The results of thisstudy resembled those initially found in boththe United Kingdom and France when thosecountries first combined 0.08% laws withautomatic license revocation.11 12In the UnitedKingdom the proportion of drivers killed withan illegal BAC declined from 25% the yearbefore the law to 15% the following year. Dur-ing the first year after France’s 0.08% law, traf-fic deaths declined 13.9%.Because all of the 0.08% law states also hadALR laws and some adopted them in closetime proximity to the 0.08% laws, our earlierstudy was not able to fully disaggregate 0.08%law eVects from ALR law eVects. Nationalstudies indicate ALR laws are associated with6%–9% reductions in alcohol related fatalcrashes.13 14Some investigators have noted thatthe paper did not detail comparison stateselection criteria and questioned whetherselection of diVerent comparison states wouldhave altered the study’s findings.15 16Theyargued that the use of multiple comparisonstates or a national comparison would be apreferable approach.Foss et al conducted a time series analysis ofalcohol related fatal crashes from 1991 through1996 before and after North Carolina adopteda 0.08% law in 1993.17They did not find a sta-tistically significant reduction in alcohol relatedfatalities after the law. They also compared theproportion of drivers in North Carolina in fatalcrashes with a BAC of 0.01% or higher duringthe 33 months before and the 39 months afterNorth Carolina’s 0.08% law to the proportionin the 37 states without a 0.08% law. Using ananalytic approach similar to that used in ourearlier paper, North Carolina experienced a6% greater decline during the post-law period.A similar decline was found among drivers witha BAC of 0.10% or higher. Neither decline wasstatistically significant when compared to non-0.08% law states. Given the number of crashesin these states, an 8% greater post-law declinein North Carolina would have been needed forstatistical significance. That analysis had lessthan 80% power to detect a 10% post-lawreduction in study outcomes and less than 60%power to detect an 8% decline. In this context,statistical power describes the likelihood ofdetecting a true 0.08% law eVect. Mostresearchers would argue that a study shouldhave power of 80% or higher. No power calcu-lations were presented for the time seriesanalyses, making these null findings diYcult tointerpret. In studies of single states changing atraYc law, potentially meaningful post-lawComparison states were selectedreductions in alcohol related traYc deaths maynot reach statistical significance. The samemagnitude of decline however, if observed inmultiple states adopting the law, can be statis-tically significant.Two multistate studies of 0.08% laws wererecently published.15 18Apsler et al studied thefirst 11 states to adopt 0.08% laws.15Theyexamined each state separately using interven-tion model time series analysis of trends in theratio of fatal crashes involving drivers withBAC of 0.10% or higher relative to fatal crasheswith no driver alcohol involvement. Examiningdata from the Fatality Analysis Reporting Sys-tem from 1982–97 they found 0.08% lawseither alone or in conjunction with ALR lawswere associated with significant declines inseven states. In five of those states, declineswere specifically associated with 0.08% lawsalone. No comparison areas were included inthe analysis to rule out regional or nationalsecular trends. Voas and Tippetts conducted anational study from 1982–97 and identified an8% decline in the proportion of drivers withpositive BACs involved in fatal crashes relativeto other fatal crashes.18Using regression mod-els they determined this reduction was inde-pendent of other drinking while under theinfluence laws such as 0.10% per se laws andALR laws as well as safety belt laws and demo-graphic, economic, and seasonal factors andper capita alcohol consumption. They pro-jected that there would be 500–600 fewerdeaths nationwide if all states adopted 0.08%laws.In a review of all the 0.08% law studies citedabove the United States General AccountingOYce concluded “there are strong indicationsthat 0.08% BAC laws in combination withother drunk driving legislation (particularlylicense revocation laws), sustained public edu-cation and consistent enforcement eVorts cansave lives”.16However,the report also indicated“the evidence does not conclusively establishthat 0.08% BAC laws by themselves result inreduction in the number and severity of alcoholrelated crashes”.There is a need to further explore whetherlowering the legal blood alcohol limit from0.10% to 0.08% produces reductions inalcohol related fatal crashes beyond thatachieved by administrative license revocationlaws.STATES RECENTLY ADOPTING 0.08% LAWSIn 1993 and 1994, six states not included inour first study10lowered their criminal per selegal blood alcohol limits from 0.10% to 0.08%(Kansas,North Carolina,Mexico, New Hampshire, and Virginia) (table1). This study explores whether these newer0.08% laws reduced alcohol involvement infatal crashes and whether the declines wereindependent of implementation of ALR laws.The analysis period extends beyond previouslypublished studies into 1998.Florida,NewTable 1 Analysis periods:recent 0.08% law states and comparison statesNew 0.08% law statesDate of law Comparison stateAnalysis periodKansasNorth CarolinaFloridaNew MexicoNew HampshireVirginiaJuly 93October 93January 94January 94January 94July 94OklahomaTennesseeGeorgiaColoradoConnecticutMarylandJuly 88–June 98Oct 88–Sept 98Jan 89–Dec 98Jan 89–Dec 98Jan 89–Dec 98July 90–June 98110Hingson,Heeren,Winter

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MethodsThis study compared fatal crash trends in thesix states that adopted 0.08% laws between1993 and 1994 with nearby states that retained0.10% as their legal blood alcohol limit. Wesought to address criticisms of our earlieranalysis of the first five states to adopt 0.08%legislation by (1) explicitly describing compari-son state selection criteria, (2) comparingstates with new 0.08% laws to matchedindividual comparison states as well as compar-ing them to all other states without 0.08% laws,and (3) conducting separate analyses of statesadopting 0.08% laws and ALR in close timeproximity and those that adopted 0.08% lawsseveral years after they adopted ALR laws.Thislatter analysis was done to assess whether0.08% laws have eVects independent of ALRlaws.We searched for comparison states which (1)were contiguous, (2) had similar populationsize, (3) had 75% or more of fatally injureddrivers tested for BAC, and (4) had similarpre-0.08% law trends in the proportion of fatalcrashes that were alcohol related.Five of the sixcomparison states met all our criteria. NewHampshire did not share a common borderwith a New England 0.10% law state. Vermontand Maine have 0.08% per se laws and Massa-chusetts adopted a 0.08% ALR law in 1994.Consequently, New Hampshire was comparedwith Connecticut, the most populous state inNew England that retained a legal BAC of0.10%. We selected comparison states thatwere contiguous or from the same geographicregion because they would be more likely toexperiencesimilareconomicweather patterns that could aVect trends infatal crashes.In each pair of states, we examined themaximum equal number of pre-law andpost-law years for which fatal crash data wereavailable. Table 1 lists the 0.08% law states,their comparison states and the analysisperiods.We examined (1) the proportion of drivers infatal crashes who had BACs at 0.10% or higherand (2) the proportion of fatal crashes thatwere alcohol related,where alcohol was presentin a driver or pedestrian at BACs of 0.10% orhigher. We also examined fatal crash data fromthe United States Department of Transporta-tion Fatality Analysis Reporting System. Alco-hol results were derived based on imputationalmethods used by the National Highway TraYcSafety Administration to calculate annual stateand national data on alcohol involvement infatal crashes.19This method uses actual bloodalcohol test results when available and esti-mates the proportion of untested drivers andcrashes where alcohol was present at levels of0.01% to 0.09% and at 0.10% and higherbased on characteristics identified in stateswith high levels of alcohol testing to signifi-cantly predict alcohol involvement in fatalcrashes with a high degree of accuracy.We useddata calculated by the imputational method.This method controls for any pre-law topost-law variability between 0.08% law andtrends andcomparison states in the percentage of driverstested for alcohol.The proportion of drivers in fatal crasheswho had raised BACs of 0.10% or higher wasexamined instead of the absolute number ofdrivers in fatal crashes with raised BACs tocontrol for the long term downward trend infatal crashes over the last decade and changesin exogenous variables that might influencedriver involvement in fatal crashes such as theeconomy, safety characteristics of vehicles andhighways, and the price of fuel. For similarreasons, we examined the proportion of fatalcrashes that were alcohol related rather thanthe absolute number of alcohol related fatalcrashes.Within each state, the change in the level ofalcohol involvement in fatal crashes from thepre-law to post-0.08% law period is describedthrough the ratio (relative risk) of the post-lawto pre-law proportion of crashes involvingalcohol according to the measures describedabove. A relative risk of less than 1.0 indicateda reduction in the level of alcohol involvement.This relative risk (RR) is related to thepercentage change in crashes with drivers withhigher BACs:100% × (ppost− ppre)/ppre= 100% × (RR−1)and changes are described through this per-centage change.Within each state pair, the relative change(and the 95% confidence interval) in theproportion of alcohol involved crashes in thelaw state relative to the control state was calcu-lated as the ratio of the two relative risks. Sub-tracting 1 from this ratio gives the percentagechange in the proportion of alcohol involvedfatal crashes in the 0.08% law state relative tothe comparison state.Meta-analytic methods were used to calcu-late an overall relative change due to 0.08%laws across the set of six state pairs.20Thisoverall eVect is a weighted average of the indi-vidual state eVects, where states with morecrashes are weighted more heavily. A test ofheterogeneity of eVects across the six state pairswas conducted to test the significance of stateto state variation in eVects. Regardless of theobserved variation in eVect, the relative changein the proportion of fatal crashes involvingalcohol was treated as a random eVect in themeta-analysis. A pooled estimated and stand-ard error for the natural log of the ratio of rela-tive risks from each state pair were calculated.This estimate and its 95% confidence intervalwere transformed back to the scale of the ratioof relative risks for presentation, and subtract-ing one from this ratio gives an estimate for theoverall percentage of change in the proportionof alcohol involved fatal crashes in the 0.08%law states relative to control states.In a commentary on meta-analytic ap-proaches DerSimonian and Laird indicate thatmeta-analysis “is becoming increasingly popu-lar in medical research where information onthe eYcacy of a treatment is available from anumber of clinical studies with similar treat-ment protocols. If considered separately anyone study may be either too small or too limitedBlood alcohol limits and fatal crash involvement111

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in scope to come to unequivocal or generaliz-able conclusions about the eVect of a treat-ment. Combining the findings across suchstudies represents an attractive alternative tostrengthen the evidence about the treatmenteYcacy”.20They caution against integrating results fromstudies that are diverse in terms of design andmethods used. This is clearly not a problem inthe analysis we conducted because in this studyall six states adopted 0.08% criminal per selaws within a one year time period and exactlythe same outcome measures and comparisonstate selection criteria were used in each analy-sis.Of note, four of the 0.08% law states (Kan-sas,NorthCarolina,Mexico) had ALR laws in eVect for three ormore years before the legal limit was lowered to0.08%, most if not all of the pre-0.08% lawanalysis periods in those states. Hence, simul-taneous enactment of ALR laws could notaccount for any diVerential post-0.08% lawreductions in alcohol related fatal crashes inthose states. Analyses were repeated for thosestates as a group.Florida, andNewResultsDRIVERS IN FATAL CRASHES WITH RAISED BACSBased on the meta-analysis, the six 0.08%states experienced a 6% greater relative post-0.08% law decline in the proportion of driversin fatal crashes with raised BACs at 0.10% orhigher (p<0.01, table 2). The proportion ofdrivers in fatal crashes with raised BACsdeclined 26.1% from 0.218 (8545/39 057) to0.161 (6693/41 408) in 0.08% law states. Inthe comparison states, the decline was 20.2%from 0.223 (6894/30 852) to 0.178 (6002/33 634). Each 0.08% law state experienced agreater decline than its respective comparisonstate. There was no significant variation in0.08% law eVect across the six state pairs.In the four 0.08% law states with ALR lawsin place long before the 0.08% limit wasadopted, the meta-analysis indicated the rela-tive post-0.08% law decline in the proportionof drivers with raised BACs was also 6%greater than their comparison states experi-enced (p<0.02). Those four 0.08% law statesexperienced a 27.5% post-0.08% law declinefrom 0.218 (7297/33 444) to 0.158 (5607/35 586). Their comparison states experienceda 21.3% decline from 0.230 (5745/24 972) to0.181 (5030/27 853). Results were similarwhen we examined the proportion of drivers infatal crashes with BACs at 0.01% or higher(data available on request).ALCOHOL RELATED FATAL CRASHESBased on our meta-analysis, the 0.08% lawstates experienced a relative 5% greater post-law decline in the proportion of fatal crashesthat involved alcohol at BACs of 0.10% orTable 2blood alcohol limit in six statesProportion of drivers in fatal crashes with a BAC of 0.10% or higher before and after the passage of 0.08% legal0.08% Law states andcomparison statesProportion before0.08% law (n)Proportion after0.08% law (n)% Change inproportion (RR)Ratio of the RRs(95% CI)Kansas (0.08%)Oklahoma0.24 (649/2723)0.23 (928/4114)0.19 (574/3068)0.18 (885/4821)−22% (0.78)−19% (0.81)0.96 (0.85 to 1.10)North Carolina (0.08%)Tennessee0.20 (1847/9381)0.25 (1929/7594)0.15 (1507/9997)0.20 (1704/8361)−23% (0.77)−20% (0.80)0.95 (0.88 to 1.04)Florida (0.08%)Georgia0.21 (3925/18499)0.21 (2012/9755)0.15 (2875/19739)0.15 (1616/10585)−31% (0.69)−26% (0.74)0.93 (0.86 to 1.00)New Mexico (0.08%)Colorado0.31 (875/2841)0.25 (876/3509)0.23 (651/2782)0.20 (825/4086)−24% (0.76)−19% (0.81)0.94 (0.83 to 1.06)New Hampshire (0.08%)Connecticut0.23 (220/944)0.28 (648/2329)0.18 (155/851)0.23 (502/2137)−22% (0.78)−16% (0.84)0.93 (0.75 to 1.14)Virginia (0.08%)Maryland0.22 (1028/4669)0.14 (501/3551)0.19 (931/4971)0.13 (469/3644)−15% (0.85)−9% (0.91)0.93 (0.81 to 1.07)Overall law eVect0.94 (0.90 to 0.98)BAC = blood alcohol content; CI = confidence interval; RR = relative risk.Table 3passage of 0.08% legal blood alcohol limit in six statesProportion of fatal crashes involving a driver or pedestrian with a BAC of 0.10% or higher before and after the0.08% Law states andcomparison statesProportion before0.08% law (n)Proportion after0.08% law (n)% Change inproportion (RR)Ratio of the RRs(95% CI)Kansas (0.08%)Oklahoma0.36 (664/1834)0.36 (994/2778)0.29 (589/2049)0.30 (960/3217)−21% (0.79)−17% (0.83)0.95 (0.85 to 1.07)North Carolina (0.08%)Tennessee0.36 (2217/6209)0.40 (2021/5104)0.28 (1847/6512)0.33 (1834/5546)−21% (0.79)−16% (0.84)0.95 (0.89 to 1.02)Florida (0.08%)Georgia0.38 (4568/12035)0.35 (2292/6489)0.29 (3611/12537)0.28 (1882/6836)−24% (0.76)−22% (0.78)0.97 (0.92 to 1.04)New Mexico (0.08%)Colorado0.50 (1060/2115)0.38 (928/2441)0.41 (814/2003)0.33 (910/2735)−19% (0.81)−12% (0.88)0.93 (0.84 to 1.02)New Hampshire (0.08%)Connecticut0.35 (232/657)0.42 (678/1608)0.29 (167/572)0.37 (544/1488)−17% (0.83)−13% (0.87)0.95 (0.79 to 1.15)Virginia (0.08%)Maryland0.35 (1133/3230)0.26 (632/2415)0.31 (1037/3381)0.25 (591/2326)−13% (0.87)−3% (0.97)0.90 (0.80 to 1.01)Overall law eVect0.95 (0.92 to 0.99)BAC = blood alcohol content; CI = confidence interval; RR = relative risk.112Hingson,Heeren,Winter

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higher,p<0.01 (table 3).As a group,the 0.08%law states experienced a 21.4% post-lawreduction from 0.379 (9874/26 080) to 0.298(8065/27 054). The comparison states experi-enced a smaller decline, 16.0% from 0.362(7545/20 835) to 0.304 (6722/22 148). Again,each 0.08% law state experienced a greaterdecline than its respective comparison state.There was no significant heterogeneity in trendbetween 0.08% law states.In the four 0.08% states with longstandingALR laws, the meta-analysis indicated the rela-tive post-law decline was also 5% greater in the0.08% law states than their comparison states(p<0.03). As a group, 0.08% law states withlong standing ALR laws experienced a 22.5%reduction in the proportion of fatal crashesinvolving alcohol at 0.10%+ from 0.383(8509/22 193) to 0.297 (6862/23 101) whiletheir comparison states experienced a 17.8%decline from 0.371 (6235/16 812) to 0.305(5586/18 334). Results were similar when weexamined trends in the proportion of fatalcrashes involving alcohol at 0.01% or higher(data available upon request).DiscussionOn both measures of alcohol involvement infatal crashes examined in this study, recent0.08% law states experienced significantlygreater post-law declines than their compari-son states. These declines were significant notin each individual 0.08% state relative to itspaired comparison state, but in the 0.08% lawstates as a group relative to the comparisonstates as a group. These are not contradictoryfindings. Given the number of crashes in eachstate, the statistical power of showing a signifi-cant decline in any individual state was low.The power to detect an 8% post-law decline,asreported by Voas and Tippetts,18in individual0.08% law states in this study was between12% and 60%. By pooling the results acrossstates,using meta-analysis,the statistical powerwas stronger. The meta-analysis had 97%power of significantly detecting such a decline.Further, all six 0.08% law states had greaterpost-law declines than their respective com-parison states and there was no significantheterogeneity in eVect between 0.08% lawstates.The relative post-0.08% law declines weresignificantly greater, even in 0.08% law stateswith longstanding ALR laws, suggesting thepost-0.08% law declines were independent ofALR laws. One comparison state, Tennessee,did not have an ALR law.Even if we deleted theNorth Carolina-Tennesseeanalysis of states with longstanding ALR laws,the post-law declines in 0.08% states withlongstanding ALR laws were significantlygreater than their comparison states againshowing eVects of 0.08% laws independent ofALR. Georgia, Florida’s comparison state,adopted an ALR law during the study periodafter Florida adopted its 0.08% law.That madeit more diYcult for us to detect the greaterpost-0.08% law reductions we found on studyoutcomes in Florida.pairfromourAll of the 0.08% states had criminal per selaws before the study period as did fourcomparison states Oklahoma, Georgia, Colo-rado, and Connecticut. In addition, all states inthe study except New Hampshire had safety beltlaws throughout the study. Also, all states had aminimum legal drinking age of 21 before thestudy period.Thus,passage of those laws duringthe study period did not confound results.Of note, the comparison states in this studyexperienced very similar trends on studyoutcomes during the study period as allremaining states in the United States without0.08% laws. There were no significant diVer-ences on study outcomes from the pre-law topost-law periods between comparison statesand other non-0.08% law states. Also, thedecline in study outcomes were significant inthe 0.08% law states relative to these other0.10% law states. Thus, it is unlikely that therewere any biases in the selection of comparisonstates.A limitation of this study was that the level ofalcohol testing of fatally injured drivers was notas high and consistent as in an earlier analysis ofthe first five states with 0.08% laws. Conse-quently,we were not able to examine the eVectsof the law on drivers with BACs of 0.08% and0.15% and higher. None the less, this studyreplicates the earlier analysis of the first five0.08% law states, which indicated 0.08% lawssignificantly reduce the proportion of fatalcrashes that involve alcohol. Further, this studyidentified eVects of 0.08% laws that were inde-pendent of ALR legislation. While the 0.08%reductions in alcohol related fatal crashes in thisstudy were 5%–6% and smaller than the 16%reduction observed earlier in states passing0.08% laws and ALR laws in close timeproximity,the decline in the more recent 0.08%law states is close to what might have beenanticipated given that ALR laws have beenfound in national studies to produce 6%–9%reductions in alcohol related fatal crashes.13 14In 1998 there were 8503 fatalities in crashesinvolving alcohol at levels of 0.10% or higher instates that had not yet lowered the legal per selimit to 0.08%. If all those states were to adopta 0.08% per se limit and were to experience the5% reduction in alcohol related traYc crashesexperienced by these recent 0.08% law states,400–500 fewer fatalities would occur annually.Currently, 33 states do not have 0.08% crimi-nal per se legal blood alcohol limits and 10states have still not adopted ALR laws. Allstates should adopt both ALR and 0.08% laws.1 US Department of Health and Human Services. HealthUnited States 1996–1997 and injury chartbook. Washington,DC: DHSS, 1997. (DHHS Publication No PHS 97-12327-0248 (7/97).)2 National Highway TraYc Safety Administration. TraYcsafety facts 1998: alcohol. Washington, DC: Department ofTransportation, National Center for Statistics and Analy-sis, 1999.3 National Highway TraYc Safety Administration. Settinglimits, saving lives: the case for .08% BAC laws. Washington,DC: NHTSA, 1997. (Publication No DOT HS 808 524.)4 Moskowitz H, Burns M. EVects of alcohol on drivingperformance. Alcohol Health and Research World 1990;14:12–14.5 Mortimer RG, Sturgis SP. EVects of low and moderate lev-els of alcohol on steering performance. In: Israelstam S,Lambert S, eds. Alcohol, drugs and traYc safety. Toronto,Canada: Addiction Research Foundation, 1975: 329–45.Blood alcohol limits and fatal crash involvement113

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6 Damkot DK,Perrine MW,Whitmore DG,et al.On the road:driving behavior and breath alcohol concentration.Vols I and II.Washington, DC: Department of Transportation, 1975.(Technical report DOT HS 364 37567.)7 Zador P. Alcohol-related relative risk of fatal driver injuries inrelation to driver age and sex.J Stud Alcohol 1991;53:301–10.8 Roger PN. The general deterrent impact of California’s .08%blood alcohol concentration limit and administrative per selicense suspension laws. Sacramento, CA: Department ofMotor Vehicles, 1995.9 Johnson D, Fell J. The impact of lowering the illegal BAClimit in five states in the US. Washington, DC: US NationalHighway TraYc Safety Administration. 39th Annual Pro-ceedings of the Association for the Advancement of AutomotiveMedicine.Chicago, IL, 16–18 October 1995.10 Hingson R,Heeren T,Winter M.Lowering state legal bloodalcohol limits to 0.08%: the eVects on fatal motor vehiclecrashes. Am J Public Health 1996;86:1297–9.11 Ross HL. Law science and accidents: the British RoadSafety Act of 1967. Journal of Legal Studies 1973;2:1–79.12 Ross HL. Deterring the drinking driver: legal policy and socialcontrol. Lexington, MA: Lexington Books, 1982.13 Zador P, Land A, Fields M, et al. Fatal crash involvementand laws against alcohol impaired driving. J Public HealthPolicy 1989;10:467–85.14 Klein T. Changes in alcohol-involved fatal crashes associatedwith tougher state alcohol legislation. Washington, DC:National Highway TraYc Safety Administration, 1989.(Contracts No DTNH-22-88-L-07045.)15 Apsler R, Chan AR, Harding W. The eVects of 0.08% BAClaw. Washington, DC: National Highway TraYc SafetyAdministration, 1999.16 General Accounting OYce. Highway safety’s eVectiveness ofstate .08 blood alcohol laws. Washington, DC: GeneralAccounting OYce, 1999. (GAO/RCED-99-179.)17 Foss D, Stewart R, Reinfurt D. Evaluation of the eVects ofNorth Carolina’s 0.08% BAC law. Chapel Hill, NC:Highway Safety Research Center, University of NorthCarolina, November 1998.18 Voas R, Tippetts AS. Relationship of alcohol safety laws todrinking drivers in fatal crashes. Washington, DC: NationalHighway TraYc Safety Administration, 1999.19 Klein T. Methods for estimating posterior BAC distribution forpersons involved in fatal crashes. Washington, DC: NationalHighway TraYc Safety Administration, 1986. (DOT HS807 094.)20 DerSimonian R, Laird N. Meta-analysis in clinical trials.Control Clin Trials 1986;7:177–88.Brazil bans computer games for violent contentBrazil’s Justice Ministry recently banned six computer games for their violent content, includ-ing one that they said encouraged a medical student to go on a deadly shooting rampage lastmonth in a movie theatre, Reuters reported in December. The games the Justice Ministrybanned stores from selling are Doom, Mortal Kombat, Requiem, Blood, Postal, and Duke Nukem.The ministry also said it would rule on other games with violent content in 120 days. “Thegames are considered violent and aVecting people who play them, particularly children”, theJustice Ministry spokeswoman said.“As for Duke Nukem,the ministry regulation says its virtualworld may have motivated Mateus da Costa Meira to stage the cinema shooting on November3 in Sao Paulo”. Stores that violate the ban will be fined $11 000 per day.Accident man gets £3526 billA pub landlord knocked down by a bus has received a £3526 bill for damaging the vehicle.Norman Green, 51, of Thornbury, near Bristol, was crossing a city centre street when he wassent sprawling and suVered four broken ribs, which laid him oV work for 14 weeks. He wasstunned when the bus company asked him to pay for repairs to a light and windscreen bro-ken in the collision and threatened to take him to court if he refused to pay.The company saidthe accident happened because “Mr Green was not looking where he was going” and it hadsuspended the summons until his finances improved.Screening teens for suicideIn spite of the fact that suicide is the third leading cause of death among adolescents,less thanone quarter of US pediatricians and family physicians screen these patients for risk factorsassociated with suicide. A recent study reported nearly one half of the 600 physicianssurveyed reported that at least one of their patients had attempted suicide in the past year.Routine screening was associated with more frequent counselling about safe storage of fire-arms and car occupant safety. Apparently, one barrier (or excuse) for not screening moreoften is concerns about confidentiality. Another may be the lack of evidence that the coun-selling provided is eVective (Arch Pediatr Adoles Med 2000;154:162–8).Surviving massive burnsA surprising report in JAMA suggests that most children who survive a massive burn have asatisfying quality of life.The study by Sheridan and colleagues from the highly respected Shrin-ers Burn Hospital in Boston was based on an evaluation of 68 children who had burns involv-ing more than 70% of their body surface.The assessment took place an average of 15 years afterthe injury. The burned children were compared with age matched general population normsusing a standardized measure. The unexpectedly good results are either a tribute to the excel-lentaftercareprogramormayreflectweaknessesinthemeasureitself(JAMA2000;283:69–73).Aggressive children? Is it hormones after all?A study shows an association between low levels of salivary cortisol and early and persistentaggression in boys 7–12. The key finding is aggression that starts early and persists amongthis subgroup of children.The study is based on a four year follow up of 38 school aged boys.Aggression was measured by peer evaluations. Those with low cortisol levels on twooccasions displayed three times as many aggressive symptoms and were three times morelikely to be chosen as most aggressive by their peers. Interestingly, the investigator noted that“stress delivered to a pregnant female mammal can permanently reset the cortisol system inthe infant” (Arch Gen Psychiatry 2000;57:38–43).114Hingson,Heeren,Winter